A Note from the Chief 3 CIVT 5 Heart Failure and Transplant

A Note from the Chief
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CIVT
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Heart Failure and Transplant
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Cellular Therapies
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Cardiovascular Imaging
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Electrophysiology
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Adult Congenital
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Prevention and Women's Health
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Fellowship
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The Future of Cardiology at CUMC
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INTRODUCTION
The normal heart is a thing of beauty. It
pumps between 1,500 and 2,000 gallons of
blood every day and sends it on a journey of
thousands of miles, all within the confines of
a single human body. Over the course of a 70year lifetime, it beats about 2.5 billion times:
70 times a minute, 100,000 times a day, 36.5
million times a year.
All of this happens thanks to an exquisitely
timed and orchestrated dance between the
four chambers of the heart—its upper atria
and lower ventricles. First, the right atrium
receives dark blue, oxygen-poor blood from
the rest of the body, where it’s been used as
nourishment. It contracts and pumps the
depleted blood through the tricuspid valve into
the right ventricle, which then pumps the blood
through the pulmonary valve into the lungs.
There, the blood sucks up oxygen, growing
rich and vital and red again, before it’s
pumped back into the heart. The newly revitalized blood travels first through the left
atrium and then into the left ventricle, which
must contract with enough power to send
that blood flooding out, through the aortic
valve, along the cardiovascular superhighway
of blood vessels to the most distant parts of
the body. This perfectly calibrated cycle happens about once every second, and most of
the time we don’t even notice it.
But when things go awry—a faulty valve, a
blocked artery, a clot in the network of vessels
and veins that both feed and feed on the
heart—this magnificent machine can become
the source of untold suffering, or death.
The burden of heart disease on our society is
growing: in the U.S. alone, more than 70 million people have some type of cardiovascular
disease, and as our population ages, we can
expect significant increases in coronary artery
disease, heart failure, and stroke.
“All of our actions take their hue from the complexion
of the heart, as landscapes their variety from light.”
Cardiovascular disease has been the No. 1
cause of death in the United States every year
since 1900, except 1918 (the last year of
World War I). It claims more lives than the
next seven leading causes of death combined,
including cancer, accidents, influenza and
pneumonia, and diabetes. Today, one of every
2.6 Americans will die of some cause related
to their heart. The price of all this heartsickness: nearly $400 billion a year in direct and
indirect costs.
The sole mission of Columbia’s cardiology
program, one of the oldest and most respected
in the world, is promoting cardiovascular
health. Our world-class faculty of more than
150 clinicians, researchers, and educators are
the leaders in their field, experts in every
aspect of cardiovascular medicine, from heart
failure and heart transplantation to interventional cardiology, cardiovascular imaging, and
heart disease prevention. Just as the chambers
of the heart work together in perfect synchrony, so too do the many specialists in our
division of cardiology collaborate to bring
state-of-the-art diagnostic tools, treatment
options, and prevention strategies to more
than 50,000 patients every year.
Francis Bacon
THE STATE OF THE HEART
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ALLAN SCHWARTZ, M.D.
A NOTE FROM THE CHIEF
If we are to develop newer, more effective
therapies and make them available to a broader patient population, we must invest in more
integrated research, and more efficient translation of basic research findings into new
therapeutics. The future of medicine lies in
breaking down old barriers both horizontally
—between divisions and departments like
biology and chemistry, neurology and cardiology—and vertically, between the basic sciences and clinical practice. Our focus, as the
Division of Cardiology continues its extraordinary growth, is on cross-disciplinary centers
and initiatives that will position Columbia to
achieve goals in taming cardiovascular disease
that are beyond our reach today.
Allan Schwartz, M.D., Seymour Milstein and
Harold Ames Hatch Professor of Clinical
Medicine and Chief, Division of Cardiology,
Department of Medicine, Columbia University
College of Physicians & Surgeons
In 2001, Columbia’s cardiology program was
ranked 28th in the country by U.S. News and
World Report. Just four years later, thanks to
visionary investments in faculty, facilities, and
technology, the Division of Cardiology ranks
in the top ten in the nation.
I don’t think there are any other cardiovascular
programs in the country today that have the
combined breadth and depth of Columbia’s.
From the world’s largest and most renowned
heart failure and transplant program, to international pioneers in interventional cardiology,
to world-class electrophysiology, molecular
cardiology, and atherosclerosis programs, there
is no aspect of cardiology that is not represented
by top scientists and clinicians at Columbia.
The field of cardiology is rich with promise as
we seek to meld basic science and clinical
practice, using approaches such as molecular
biology, high throughput cellular screening,
genomics, and proteomics. But such 21st-century science requires ambitious investments in
people and resources. To make these investments, we will soon launch one of our most
visionary campaigns to date, designed to
establish Columbia as an unparalleled leader
in cardiovascular science. Our goal, and our
challenge, with such a campaign is to develop
the space, programs, and opportunities needed
to continue to recruit and retain the finest
minds in our field.
This is not merely science for science’s sake. At
the end of the day, it all comes back to the
patient. The research we do, the young scientists
and clinicians we train—it is all, ultimately,
focused on saving and improving the lives of
our patients. I believe that tomorrow we will
be able to treat the patients we are failing
today, because of the things we do here, the
clinicians and scientists we train, and the
knowledge we create.
But it is not enough.
Further understanding of the genetic, molecular, and cellular bases of cardiac disease will
allow more effective and targeted treatments
to be developed.
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CENTER FOR INTERVENTIONAL VASCULAR THERAPY (CIVT)
KEEPING AN OPEN HEART
“Where complex cases are routine.” That
could well be the motto of the Center for
Interventional Vascular Therapy (CIVT) at
Columbia, whose team of more than 20 interventional cardiologists and other medical
experts in minimally invasive cardiac care
joined the Division of Cardiology in 2004.
The unique expertise of this pioneering group
has transformed the treatment of coronary
disease at Columbia.
“We’re willing to take on the most challenging
cases, the ones that other centers might not
want to do. Whether it’s complex multivessel
disease, technically challenging anatomy, or
patients with multiple comorbidities, we’re
used to it,” says the Center’s Director, Jeffrey
Moses, M.D., a world-renowned expert in
complex angioplasty, who in 2002 served as
the lead investigator on the U.S. clinical trial
that led to the approval of drug-coated stents.
Indeed, name any advance in interventional
cardiology over the past two decades, and it’s
likely that one or more of CIVT’s cardiologists
played a key role in making it happen.
In the first year after CIVT became a part of
the Division of Cardiology, Columbia’s angioplasty rate jumped to more than 3,000 per
year. Today, it is one of the world’s leading
tertiary referral centers for complex cardiovascular and endovascular disease, says Associate
Director Martin Leon, M.D., who has been the
principal investigator on more than 20 major
clinical interventional trials.
The philosophy behind the group’s success,
says Dr. Moses, is a patient-focused one. “The
hallmark of our group is that we’re always
trying to fulfill the unmet clinical need. This
isn’t technology for technology’s sake.” CIVT
was actively enrolling patients in more than
30 cutting-edge clinical research protocols by
the end of its first year at Columbia.
Dr. Leon also created the Cardiovascular
Research Foundation, now an affiliate of
Columbia, to advance research and education
in the field of interventional cardiology. Its
studies include several large clinical trials, such
as the HORIZONS (Harmonizing Outcomes
with Revascularization and Stents) trial, which
will enroll 3,400 patients at 200 sites worldwide over the next two to three years to test
the efficacy of stents and anticoagulants in
heart attack patients, and the NIH-sponsored
FREEDOM trial, testing the optimal revascularization strategy in diabetic patients.
These pioneers of stenting are also hard at
work on the next generation of cardiac stents.
They’re developing new and improved
catheter delivery systems to navigate more
complex areas of the coronary tree, making
stents safer, with less risk of clotting, and
more available to a wider group of heart
patients. Soon, they expect to conduct human
trials of the first bioabsorbable stent, made not
of metal but of a unique blend of polymers
that are less likely to trigger new blockages in
the artery.
“I thought my heart had been wounded with the claws of a lion.”
William Shakespeare
As You Like It
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FRAGILE VESSELS: PERIPHERAL ARTERIAL DISEASE
The blood vessels in the heart aren’t the only ones that can become clogged
and need to be reopened. Throughout the body—mainly in the arteries that
lead to the brain, kidneys, and legs—fatty deposits can build up, restricting
circulation. Approximately 20% of people over age 55 have such blockages in
the legs, known as peripheral arterial disease (PAD).
“Atherosclerosis is a systemic problem that affects the whole body,” says
Elizabeth Ratchford, M.D., who joined the Division of Cardiology in 2003 to
establish its new Vascular Medicine program. “Problems in the heart often
mean problems in the circulation of the legs and the carotid arteries of the
neck as well, so the people at risk for a heart attack are frequently at risk for
PAD and stroke.”
CIVT’s increasing work with peripheral arterial disease—using stents to treat
blockages in the legs and the neck, for example, just like in the heart—fits well
with the Vascular Medicine Program. “We find the blockages, and the CIVT
physicians open them. We follow the patients before and after the placement
of the stents, to treat the risk factors that led to the blockages in the first place—
such as smoking, hypertension, diabetes and high cholesterol,” says Dr. Ratchford.
Diagnosis of PAD takes place in the Cardiovascular Ultrasound Laboratory. ”We
use ultrasound to look for plaque and to assess its impact on the blood flow
Clogged vessels aren’t the only cause of heart
disease. Some people have defective heart
valves that can strain the heart and cause
serious and life-threatening complications.
in the legs and in the carotid arteries,” Dr. Ratchford explains. “We also put
blood pressure cuffs on the patient’s thigh, calf, and ankle, to measure the
pressure, which helps us to find the blockages.” Columbia was one of the first
institutions to adopt this model, using the echocardiography lab as a facility for
noninvasive approaches to PAD.
“There are many mysteries in vascular medicine,” says Dr. Ratchford—mysteries
that Columbia hopes to solve through the PAD program’s research. For example,
certain risk factors appear to predispose people to blockages in specific areas.
A person with diabetes seems to be equally likely to develop blockages in the
heart and the legs, whereas smoking predisposes a person to more severe
atherosclerosis in the legs. High blood pressure, on the other hand, seems to
have a larger impact on atherosclerosis in the heart. “No one knows why some
vascular beds are affected more than others, and why some people never have
a stroke or a heart attack and instead only develop pain in their legs,” says Dr.
Ratchford. “If we could figure out why it’s happening that way, perhaps we
could block the effects.”
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THE STATE OF THE HEART
It’s estimated that at least 10 million Americans
have some type of heart valve abnormality—
and three to four million of these people have
disease severe enough to require surgery at
some point in their lives. Many of these
patients aren’t good candidates for surgery, and
they have a five-year mortality rate of 50%.
Until recently, these patients had to undergo
open-heart surgery to replace or repair the
malfunctioning valves—if they were healthy
enough to tolerate it—but research conducted
by CIVT scientists shows that many people
with valvular disease can be treated less invasively. “Many of the 125,000 patients per year
who undergo surgical aortic valve replacement could be treated with catheter-based
techniques,” Dr. Leon says.
Drs. William Gray and Allan Schwartz are
currently investigating the Evalve® Cardiovascular Valve Repair System for the treatment
of mitral valve regurgitation. With the Evalve
technology, cardiologists seek to repair the
valve non-surgically by using a catheter to
place a tiny clip over the center of the valve
leaflets (the two flaps that make up the valve).
Initial trial results have been extremely promising, with 75% of the patients who received
the clip remaining surgery free at the sixmonth mark.
A FATHER’S HEART
When Dr. Jeffrey Moses saved Daniel Wiederhorn’s life in 1999, it seemed like
a family tradition.
Nearly 15 years ago, Daniel’s father was considered “untouchable” by most
cardiac surgeons. After undergoing open-heart surgery to open several blockages in 1976, at the age of 50, the elder Wiederhorn had experienced three
more blockages, and three more surgeries. “When he had a blockage again
in the early 1990s, no doctor would work on him anymore,” says his son. “His
artery disease was just so bad.”
Fortunately, Wiederhorn’s internist knew of a cardiologist who wouldn’t be
Aiming to move experimental models and
next-generation therapies from the bench to
the bedside more quickly, in 2005 the Jack H.
Skirball Center for Cardiovascular Research
opened under the auspices of the Cardiovascular Research Foundation. It boasts
25,000 square feet of dedicated experimental
interventional laboratory space, with state-ofthe-art imaging and other technology. “It’s
one of the largest and best-equipped cardiovascular research centers in the world,” says
Dr. Leon. Some 15 research protocols began at
the Center within a month of its opening.
The last piece of the puzzle for CIVT is education, both for the public and for physicians.
With interventional therapies for cardiovascular disease expanding and evolving almost
every day, new knowledge must be spread
widely—and quickly—so that cardiovascular
specialists around the world can keep up with
the latest advances. Through the Cardiovascular Research Foundation, CIVT’s physicians host Transcatheter Cardiovascular
Therapeutics (TCT), the world’s largest privately run medical meeting, attended by more
than 11,000 medical professionals in 2005.
“Every single one of the CIVT physicians
could be running their own program at a
leading hospital, and many of them have
been,” says Dr. Moses. “But together, we create
something unique, something that is more
than just the sum of its parts.”
intimidated by this patient’s complicated cardiac history: Dr. Jeffrey Moses,
who was then working on some of the world’s first cardiac stents. When the
first FDA-approved stents were introduced in 1994, the metallic, scaffold-like
devices for propping open a blocked artery quickly became commonplace.
But in the early 1990s, they were still experimental.
“Dr. Moses put the stents in and opened him up, and saved my father’s life,”
says Daniel. “From then on, Dr. Moses was his doctor.” In 2003, Daniel
Wiederhorn’s father passed away—10 years after other doctors had given up
hope on him. “Without a doubt, if he hadn’t gone to Dr. Moses, I would have
lost my father long before.”
In December of 1999, the family history struck again. At the age of 50—just
about the same age his father had been when he had his first open-heart
surgery—Daniel Wiederhorn found himself feeling ill. “My internist had determined awhile before that I had diabetes, but I really had been feeling fine and
didn’t think I had any heart trouble,” he recalls. But while walking around during the holidays, he noticed a strange feeling in his jaw and shortness of
breath. After an electrocardiogram at his doctor’s office, he was sent straight
to Westchester Medical Center, near his home.
“There, the cardiologist said, ‘Your heart is very clogged, and we can’t put
stents in you because of your diabetes. We want to do open-heart surgery.’”
At that point, Daniel’s wife arrived, and called a halt to everything while she
phoned Dr. Moses. He immediately arranged for an ambulance and had
Daniel brought to his office.
Just as with Daniel’s father, Dr. Moses offered to treat Daniel in a way that
other doctors wouldn’t. “He said, ‘Listen, instead of cutting you open, we’ll
put in three stents, and you don’t have to go in for open-heart surgery.’ A
year later, he had to put in one more stent, and since then, with medication,
I’ve been trouble-free,” Daniel says. “If I do feel something, I just discuss it
with Dr. Moses. He’s a true gentleman. He and his team attend to you in every
detail; you really know you’ve got the best.”
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HEART FAILURE AND TRANSPLANT
RESTORING BROKEN HEARTS
Physicians who specialize in caring for heart
failure and transplant patients are “the last of
the old-time doctors,” says Donna Mancini,
M.D., Medical Director of the Center for
Advanced Cardiac Care. “We’re intimately
involved with our patients and their families.
It’s a lifelong relationship with a real bond.”
At the Center for Advanced Cardiac Care,
formed in 2004 by the merger of the heart
failure and transplant programs, cardiologists
like Dr. Mancini may have the kind of close
relationships with their patients last seen in
the days of Marcus Welby, but they’re also
state-of-the-art medical experts with 21stcentury tools. The Center is the leading heart
failure and transplant program in the nation,
with a transplant volume higher than any
other center in the country, performing
between 85 and 100 heart transplants a year.
It’s also the most successful: 93.5% of the
Center’s transplant patients are alive one
year later, compared with a national average
of about 85%.
With the aging of the population, heart failure
is on the rise in America. Almost five million
people have heart failure already, and 400,000
new cases are diagnosed every year. The causes
are many—frequently, heart failure can be the
end stage of another type of heart disease,
such as coronary artery disease, heart attack,
and arrhythmias.
Heart failure doesn’t actually mean that the
heart has failed—at least, not yet. Instead, it
means that the heart has been weakened to
the point that it’s pumping inefficiently and
can’t push out enough oxygen-rich blood to
the rest of the body. The result is much like
what happens on a major highway when the
number of lanes is reduced from four to two:
a backup of blood “traffic” in the veins leading
to the heart. The kidneys retain fluid, and the
body’s tissues can swell, sometimes causing
breathing difficulty.
Most heart failure patients are treated with
medications aimed at boosting the power of
the weakened heart and limiting its effects on
the rest of the body. Columbia’s cardiologists
have played a vital role over the years in identifying many of these drugs, which help heart
failure patients not only survive with the disease but often thrive. Physician-scientists with
the Center for Advanced Cardiac Care have
conducted instrumental research in the use of
beta-blockers to manage heart failure. More
recently, these physicians have pioneered the
use of erythropoietin to improve patients’
ability to exercise.
Ultimately, for many heart failure patients,
medication is not enough. “Their weakened
hearts are too badly damaged to sustain
them, and they will need either some kind of
mechanical assist device to keep the weakened
heart functioning, or that most precious of all
gifts: an entirely new, undamaged heart,” says
Yoshifumi Naka, M.D., Director of the
Cardiac Transplantation and Mechanical
Circulatory Support Program.
“It is the nature of the strong heart, that like the palm tree it strives ever upwards
when it is most burdened.”
Sir Philip Sidney
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UNBREAK HER HEART
It was hard to slow Kerry Keenan down. An advertising executive
By August 2003, Kerry’s condition had deteriorated to the point
with an exciting career, she traveled the world creating award-
that doctors upgraded her priority status on the heart transplant
winning campaigns for clients like McDonald’s and Sony. She’d
waiting list. Dr. Mancini told her the wait for a new heart would
always been the picture of health, so when Kerry started feeling
likely be about six months—but just three weeks later, on the
sick, tired, and run down in early 2001, she assumed that the 16-
night of Kerry and Michael’s second anniversary, they woke up
hour days and constant airline flights were catching up with her.
to the sounds of beeper, cell phone, and home phone all ringing
at once.
But things kept getting worse. On a commercial shoot in
London, she felt so ill that she couldn’t walk up the stairs, and
Kerry spent 17 days in the hospital after her heart transplant—
wondered if she might have pneumonia. The symptoms piled
but says that when she awoke immediately after surgery, she
up: “I couldn’t sleep, I’d gained 15 pounds in two weeks, my
already felt better. “As soon as I was conscious, I realized I felt
ankles were swollen. I couldn’t breathe. I went to my regular
warm for the first time in years,” she says. “I looked in the mirror
doctor in April, and he told me I just needed sleeping pills.” On
and I had color in my face.”
the way out of the office, Kerry turned around and insisted,
“Something’s wrong with me. I don’t know what it is, but something’s wrong.”
Five months after her surgery, Kerry went back to work, and has
been working full-time ever since—although she took a little
time off recently, when she and Michael adopted a baby boy.
The doctor reluctantly agreed to a chest X-ray, insisting that it
Francis Michael arrived on their fourth wedding anniversary, two
wouldn’t find anything—but after viewing Kerry’s films, the radi-
years to the day after his mother received her new heart.
ologists wouldn’t let her go home. “They said my heart muscle
was enlarged, and I had fluid in my lungs and needed to be
checked into the hospital immediately.”
At little Francis’s baby shower, there were some very special
guests: the family of the young woman whose heart now beats
in Kerry’s chest. After several anonymous letters were exchanged,
Kerry was diagnosed with idiopathic cardiomyopathy—a failure
Kerry and her husband were able to meet the parents and
of the heart muscle due to unknown causes. “The first time they
brothers of the girl, who had died of a stroke after a brain
told me, I had to hear it like seven times before it sank in,” she
aneurysm. “She was a twin, the only girl in the family, and they
says. But then, throwing herself into her diagnosis with the same
loved her extraordinarily,” she says. “They are so selfless, so giv-
intensity she approached her advertising career, she began
ing, and we’re trying to include them in all the wonderful things
researching. “What was the best place to go in New York for
that have happened to us because of their incredible gift.”
cardiomyopathy? It wasn’t hard to find out that it was Columbia.”
She immediately began seeing internationally renowned heart
failure and transplant specialist Donna Mancini, M.D.
Today, says Kerry, she’s in better shape than ever, running 5Ks
and working out with a trainer. “I love Dr. Mancini. She’s excellent at what she does, and she really pushes you to do the most
Despite several experimental protocols, Kerry’s condition contin-
you can with your life,” she says. “The whole team at Columbia
ued to decline. But she remained determined to live as normal a
is just such a wonderful group. I feel like I have a thousand
life as possible. She and her fiancé, Michael Jarvela, married in
guardian angels.”
September 2001, and she continued to work at her advertising
agency. “It wasn’t easy. I’d take a taxi two and a half blocks to
work, and then two and a half blocks home again after work,
and I’d lie down on the couch, and that was it,” she said. “It was
very hard for me and my husband, because we never had that first
couple of years of marital bliss, just being a couple having fun.”
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THE STATE OF THE HEART
Such gifts are rare. Only about 2,200
donor hearts become available nationwide every year, and most patients
spend almost a year on the waiting list
before a heart becomes available. For
that reason, says Dr. Mancini, doctors
must be particularly careful in evaluating patients, making sure that they are
good candidates for transplants and
have a good chance of long-term survival. “We at Columbia have been
leaders in terms of identifying those
patients who are most in need of transplant, and we’ve continually raised the
bar in selection criteria, making it possible for patients who previously would
have been excluded to have the chance
at a new heart.”
For example, imagine a 60-year-old
man with hypertension who dies in an
auto accident. His driver’s license says
he is an organ donor, but his age and
medical history would mean that his
heart wouldn’t be given to a lower-risk
transplant candidate. But with Columbia’s
new Extended Donor Heart Transplant
Program, hearts like this one can be matched
to patients whose age or other illnesses would
have otherwise ruled them out as transplant
candidates. “It brings the possibility of a new
heart to patients who otherwise would have
no hope, without affecting the hundreds of
other patients already waiting for a heart,”
says Dr. Mancini.
Physician-scientists at Columbia have also
helped improve the odds of a heart transplant’s success, leading the way on research
into novel therapies that help suppress the
immune system’s natural impulse to reject the
“foreign” heart. “We’ve been pioneers in the
use of the drug rapamycin as an immunosuppressive therapy,” says Dr. Mancini. “We’re also
using novel monoclonal antibodies to prevent
rejection, and investigating the use of genetic
arrays to detect rejection.”
With donor hearts so rare and rejection issues
so common, over the last decade a revolution
has been taking place in the treatment of
heart failure: artificial assist devices. Originally
conceived primarily as a “bridge to transplant” therapy designed to keep patients alive
until a suitable donor heart could be found,
options like left ventricular assist devices
(LVADs) are increasingly being used as “destination therapies” for patients who would not
be candidates for transplants. Columbia cardiologists and surgeons participated in the
initial LVAD trials, and spearheaded the multicenter ReMATCH trial, which found that use
of the implanted heart pump more than doubled the likelihood that terminally ill heart
failure patients would be alive at the end of
the year.
Although implantable LVADs may allow the
heart muscle to heal, they usually don’t restore
full heart function. Columbia is now investigating ways to fill this gap, using innovative
approaches like autologous stem cell transplants—that is, from the patient’s own
cells—to spur the growth of new heart cells
and improve recovery rates.
“Ours is truly one of the flagship programs
for heart failure and transplantation,” says Dr.
Mancini. “We’re one of the largest and the
busiest centers in the world, and we’ve been at
the forefront of research for more than a
decade. But no matter how much our center
grows, we will never lose sight of the physician-patient bond that is essential to the care
we provide.”
DOES HEART FAILURE BEGIN OUTSIDE THE HEART?
New research from Columbia scientists challenges the conventional
Donald King, M.D., showed that these patients actually have larger
wisdom about the most common type of heart failure, known as
than average hearts. “We need to look elsewhere to discover the
diastolic heart failure. Patients with this condition have normal ejection
roots of this problem,” says Matthew Maurer, M.D., Director of the
fractions—the measurement of the heart’s ability to pump blood—
Clinical Cardiovascular Research Laboratory for the Elderly at New
but their hearts have trouble filling with blood in the first place.
York Presbyterian Hospital/The Allen Pavilion.
For years, scientists assumed that these patients had small, thick-
Dr. Maurer’s research suggests that many of these patients might be
walled hearts that were difficult to fill with enough blood. But in fact,
better treated with drugs aimed at the specific ailments causing the
it’s just the opposite. A unique three-dimensional echocardiography
heart failure—such as anemia, obesity, diabetes, and hypertension—
system developed by Columbia professor emeritus of radiology
rather than with treatments for heart failure itself.
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CELLULAR THERAPIES
THE INFINITE HEART
patients, with cultured cell lines just waiting
in hospital laboratories for the next person
who needs them.
What if we could grow new hearts? What
if, after a heart attack or a new case of
heart failure, doctors could instruct that
deteriorating heart muscle to replenish
itself with new, strong, undamaged tissue?
That’s the holy grail pursued by many
leading researchers at Columbia, as they
seek genetic and molecular solutions to
repair or replace damaged hearts.
“Right now, even with the most
advanced therapies available to patients
with heart attacks, we’re able to salvage,
at most, 60% of the heart muscle that
was at risk,” says Warren Sherman,
M.D., CIVT’s Director of Cardiac CellBased Endovascular Therapies. “Despite
our best efforts, the fundamental problem of persistent damage to the heart
continues.”
That’s why scientists are so excited
about research now underway at
Columbia that’s exploring cellular
therapies aimed at switching on the
machinery that creates new heart muscle,
or myocardium. One possibility, says
Dr. Sherman, are cells found in the
bone marrow, known to be a reservoir
of reparative cells. “Bone marrowderived mononuclear cells promote
vascular growth after tissue injury,” he
explains. “Several years ago, researchers
at Columbia demonstrated the fundamental role played by a specific
population of bone marrow cells in
generating a fresh blood supply to injured
myocardium. If new blood vessels can
be stimulated in patients with heart
attacks using this method, we may have
found a formula for effective ‘damage
control.’”
Dr. Itescu and his team are now awaiting FDA
approval for initial human trials of mesenchymal precursor cells. Once it’s proven that
they’re safe for use in humans, he’ll test them
in patients with acute myocardial infarctions.
Columbia scientists are also pursuing genetic
solutions to heart disease. Hina Chaudhry,
M.D., was just eight years old when she promised her mother that she would become a
heart specialist and help people like her father,
who had suffered a heart attack. Nearly 30
years later, her father is doing well—and Dr.
Chaudhry thinks she’s stumbled upon what
may be the most important gene in the heart
for regenerating cells.
Another source for such heart regeneration:
the rare but potentially rich population of
cells known as mesenchymal precursor cells,
also found in each person’s bone marrow. We
each have only a few, but Silviu Itescu, M.D.,
Director of Transplantation Immunology,
believes these few cells hold infinite promise
for rebuilding damaged hearts. “We’re able to
purify these cells to a very high level and then
grow them up in very large numbers. If we
then introduce the cells back into a small animal model of ischemic heart disease, we get
new arterials growing, and we get new heart
muscle regenerating. That results in
significantly improved heart function.”
Mesenchymal precursor cells have some
unique and exciting properties that allow
them to fly under the radar of the body’s
immune system. They seem to lack certain
surface receptors that enable the immune system to recognize them as foreign bodies. So
one or two donors of a few mesenchymal
stem cells could, in theory, help grow new
heart tissue for many unrelated cardiac
It’s called cyclin A2, and as soon as any mammal is born, it goes silent, as surely as a radio
that’s been switched off. From that point on,
the heart stops developing new cells—it grows
larger only because the cells within it grow
larger, not because more cells are born. Now,
in animal research, Dr. Chaudhry has discovered that when cyclin A2 is artificially
switched back on, new heart cells continue to
be generated. And when heart attacks are
induced in mice that have switched-on cyclin
A2, their heart tissue regenerates and retains
its ability to pump.
Dr. Chaudhry’s team has also begun testing
ways to deliver cyclin A2 as a drug, something
that could be therapeutically delivered to people with heart failure or who have just had
heart attacks. “Our current therapies for heart
failure are very limited, and the mortality rate
hasn’t budged,” she says. “We have an imperative need for cellular and molecular therapies
to change that picture.”
“Is not the core of nature in the heart of man?”
Johann Wolfgang von Goethe
THE STATE OF THE HEART
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13
CARDIOVASCULAR IMAGING
SEEING WITH THE HEART
confusion. By using one camera that simultaneously takes two pictures—one of the radioactivity emanating from the heart, and the
other of the radiation coming from a source
that goes through the chest—the SPECT
image can be corrected for attenuation and
more accurately determine what’s blocking
blood flow to the heart—and what isn’t.
Other new tools are creating a brighter picture
for heart patients as well. Columbia is one of
only five centers in the United States to offer
combined SPECT/CT scanning, a technique
that fuses the high-resolution anatomical
scanning of CT technology with the functional
imaging of perfusion SPECT scans to create a
more accurate map of heart function, while
at the same time providing coronary artery
calcium scores. This system can perform both
SPECT for blood flow and coronary CT
angiography for anatomy.
They say that every picture tells a story. In
Columbia’s cardiovascular imaging program,
that story is one of survival. State-of-the-art
imaging tools such as MRIs, CT angiography,
echocardiography, and ultrasound can paint
vivid, detailed pictures of the human heart in
real time, pinpointing problems like diseased
vessels and areas of damage after a heart
attack with astounding precision.
For some 30 years, single photon emission
computed tomography (SPECT) has helped
cardiologists diagnose atherosclerosis, using
low doses of radioactive drugs and gamma
cameras to show how blood flow is distributed through the heart. But until recently, it
had crucial limitations. The soft tissues of the
chest area can “confuse” the SPECT technology,
leading to false positive readings that appear to
show heart disease when there really is none.
A new approach called attenuation correction,
pioneered in part by Lynne Johnson, M.D.,
Director of the Nuclear Cardiology
Laboratory at Columbia, eliminates this
“Nobody has ever measured, not even poets, how
much the heart can hold.”
These calcium scores, says Dr. Johnson, may
help cardiologists determine which patients
are at greatest risk from coronary artery
disease—and therefore need more vigilant
management strategies. “Usually, the most
advanced atherosclerotic lesions are the ones
that calcify, and we can pick that up with a CT
scanner,” she explains. “We’re now involved in
a multicenter study to determine whether
coronary artery calcium scores can help us
predict a patient’s prognosis.” If, for example,
a patient’s perfusion scan looked normal but
his calcium was elevated, doctors might be
more aggressive in controlling lipid levels and
monitoring heart function than with a patient
whose normal scan was accompanied by low
calcium levels.
Columbia also has an active cardiac PET
service, directed by Dr. Sabahat Bokhari.
PET (positron emission tomography) is an
advanced nuclear imaging technology that
can measure blood flow to the heart and the
metabolism of the heart muscle. Using a very
short-lived PET tracer called rubidium, physicians can perform a complete test to look for
blockages in the heart’s blood vessels in less
than one hour.
Zelda Fitzgerald
THE STATE OF THE HEART
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15
In early 2006, Columbia began using another
exciting new tool: coronary CT angiography,
an option that allows physicians to view blockages of the coronary arteries without an arterial
catheterization. “About a quarter of the people
in this country who have a cardiac catheterization don’t have significant coronary artery
disease,” says Steven Wolff, M.D., Ph.D.,
Director of Cardiovascular MRI and CT.
“Another quarter of these patients have
significant disease, but doctors don’t do an
angioplasty—for example, if the disease is so
severe that the patient actually needs a
bypass. You don’t want to put a catheter in a
patient if you’re not going to use it to fix
what’s wrong.” Coronary CT angiography, he
predicts, will replace a lot of invasive procedures for diagnosing coronary artery disease.
SPECT and CT aren’t the only ways to visualize the heart. Division of Cardiology Associate
Chief Shunichi Homma, M.D., has played a
key role in developing ultrasound imaging of
the heart so that it can visualize cardiac structures in three dimensions, rather than in two
flat dimensions. He and his colleagues are
now using 3-D ultrasound and other recent
advances, like tissue Doppler imaging, to help
select which patients are most likely to benefit
from devices that resynchronize the heart after
an arrhythmia, like left ventricular assist
devices (LVADs) and biventricular pacers.
Led by Dr. Homma, a Cardiovascular
Ultrasound Laboratories staff of over 50—
one of the largest such programs in the
world—performs more than 25,000 echocardiograms, vascular ultrasounds, and other
studies every year.
In fact, cardiovascular ultrasound, which has
long been part of a doctor’s diagnostic arsenal,
may also be useful as a therapeutic tool. That’s
one of several intriguing possibilities being
explored by Dr. Homma and other researchers
in the cardiovascular imaging program.
Supported by the NIH, they are testing highintensity, focused ultrasound as a tool for
ablating myocardial tissue to treat patients with
arrhythmia. In one of the largest cardioembolic
stroke programs in the nation, Dr. Homma
and Dr. Marco DiTullio are assessing how well
ultrasound can predict adverse events in a
large group of northern Manhattan residents.
Dr. Homma also organized an NIH-supported
multicenter study to demonstrate the efficacy
of medical therapy for stroke patients with
patent foramen ovale, and now is responsible
for a 140-center NIH-supported study to
assess the efficacy of warfarin compared
with aspirin to reduce stroke or death in
patients with low cardiac ejection fraction
(the WARCEF trial).
For a picture of the heart that’s really worth a
thousand words, scientists are looking toward
cardiac MRI. “No other imaging technology
has the versatility of MRI,” says Dr. Wolff.
Not only can it do many of the same things
that echocardiography and nuclear imaging
can do, MRI can also produce high-resolution
images to quantify heart function, valve function, and blood flow to the heart muscle.
“We can define ventricular function, which is
important for patients with heart failure. We
can assess how leaky valves are for patients
with valve disease. We can assess viability—
whether heart tissue is alive or dead—with
more precision than any other test,” Dr. Wolff
says. Perhaps most exciting, cardiac MRI can
even pinpoint exactly where a heart attack has
happened—or is still happening. Dr. Wolff
predicts that it will become a first-line test for
patients with all kinds of heart disease within
the next few years.
“As new, advanced therapies become available
for cardiovascular disease, we need to develop
imaging techniques that are equally advanced,
so that we can choose the right patients for
the right treatments,” says Dr. Homma.
ELECTROPHYSIOLOGY
THEY’VE GOT THE BEAT
The heart isn’t just a muscle. It also has an
extensive electrical system that’s just as complex and finely tuned as the one that brings
power to your home. With each beat, electrical impulses flow to and from the heart, part
of a circuitry so delicate that one missed
connection or extra channel can cause the
irregular heartbeat patterns known as
arrhythmias.
Of course, we’ve all felt our hearts “skip a
beat” on occasion—on seeing our true love
for the first time, or hearing a mysterious
noise in an empty house late at night. Most of
the time, these sudden skips and flutters are
no cause for alarm. But for more than two
million Americans, various types of arrhythmias mean that their hearts frequently beat
too slowly, too quickly, or irregularly. This “off
beat” problem can lead to shortness of breath,
fainting, or even sudden death.
Two million people in the United States today
have arrhythmias, and particularly for the elderly, they can pose a serious risk of heart
failure or stroke. These persistent arrhythmias
were once treated with open-heart procedures
or lifelong medication management, but
today, a growing number of patients can have
their arrhythmias eliminated with a percutaneous procedure called catheter ablation.
Ablation involves heating cardiac tissue
through radiofrequency current, at frequencies of about 750 kilohertz, or about the same
as radio waves. That heat is used to burn away
and correct small patches of tissue that are
causing the arrhythmia. Once done through
open-heart surgery, most arrhythmia ablations can now be done less invasively, by
introducing the electrode to the heart by way
of a catheter.
“This technique is critically dependent on the
accuracy of the mapping that we do beforehand. First, we use three-dimensional
electro-anatomical mapping techniques to
give us a graphic description of how the electrical waves travel through the chambers of
the heart,” explains Hasan Garan, M.D.,
Director of Cardiac Electrophysiology. “If they
differ from their normal pathways, creating an
arrhythmia, we collect multiple signals to, in
essence, create one giant heartbeat that shows
us the path of the arrhythmia.”
“Sensations sweet, felt in the blood, and felt along the heart.”
William Wordsworth
THE STATE OF THE HEART
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19
Implantable devices, like biventricular pacers
and internal cardiac defibrillators, have also
substantially reduced the risk of sudden
cardiac death for many patients with arrhythmias, heart failure, and other cardiac conditions. These devices can either “shock”
patients out of an arrhythmia and back into
normal heart rhythm, or keep the two ventricles of the heart beating in synchrony with
each other.
But which patients need them, and which
ones don’t? It may be that a substantial number of patients with implantable cardiac
devices don’t need them—and some people
who do need them aren’t getting them. “Now
that we have relatively simple tools to find
people who are at reasonably high risk of sudden cardiac death, the next challenge is to
identify those apparently ‘high risk’ people
who actually don’t need ICDs,” says J. Thomas
Bigger, M.D., Medical Director of Columbia’s
Clinical Trials Network.
CHANGING CHANNELS
Sometimes, there’s nothing wrong with the structure of the heart itself. The
valves, the ventricles, the chamber size—everything is perfectly normal. And
yet this “perfectly normal” heart can suddenly lurch dangerously off beat,
developing an arrhythmia that can easily become fatal.
The problem may lie within the complicated network of valves found on the
cell membrane surrounding every cell in the heart, known as ion channels. As
electrically charged ions (such as sodium, calcium, and potassium) flow across
the membrane through these channels, they spark the electrical impulses that
radiate from the heart’s “pacemaker,” the sinoatrial node. If even one of the
dozens of ion channels found in the heart has a flaw, those impulses can
become as jittery and uncoordinated as a dancer hitting a patch of ice.
For Geoffrey Pitt, M.D., Ph.D., it’s all about calcium. Calcium ion channels, he
explains, are the ultimate signal transmitter for electrical activity within cells.
“We know that calcium regulation is abnormal in conditions like heart failure
and hypertension,” he says. By studying intracellular calcium and the ion channels that transmit it, he hopes to understand how abnormal regulation of
Using a new test called T-wave alternans,
which measures tiny heartbeat variations not
visible to the naked eye, electrophysiologists
can detect those patients whose ventricular
arrhythmias are particularly life-threatening.
Columbia scientists helped to refine and
establish the protocols for this new test, which
has proven to be an accurate predictor of dangerous arrhythmias. It is especially good for
risk-stratifying patients with heart failure and
those with non-ischemic cardiomyopathy.
“We’ve found that as many as one-third of the
people who are considered eligible to have an
ICD implanted have a normal T-wave alternans test,” says Dr. Bigger. “Those people
almost never have any sudden death events.
Advanced testing like this really helps us finetune which patients can benefit most from
these important tools.” T-wave alternans testing also reflects the action of some drugs that
are used to treat heart failure, and may prove
useful in developing next-generation heart
failure drugs.
calcium can provoke the arrhythmias that often strike people with heart failure—and ultimately, to fine-tune decision-making about which patients receive
implantable cardiac defibrillators (ICDs).
“Not all people with heart failure develop arrhythmias, and not all of them
need these devices. But right now, we don’t know which ones will and which
ones won’t,” Dr. Pitt says. “If we understand how calcium and its ion channels
interact, we could potentially develop a test that would identify who would
benefit most from ICDs.”
Another important ion channel has been dubbed BK. Since K is the chemical
label for potassium, the name just means “big potassium” (the channel has
“big potassium”-conducting properties). It’s a channel responsible for relaxing
the smooth muscles of the heart, and Columbia scientist Steven O. Marx, M.D.,
Ph.D., is studying what role it might play in a variety of cardiovascular diseases,
such as hypertension and stroke.
“Big potassium” may also play a role in coronary artery spasm—the sudden,
unpredictable narrowing of the coronary arteries that temporarily limits blood
flow to the heart and increases the risk of a heart attack. Although it’s more
common in people with existing coronary artery disease, coronary artery spasm
can happen even in relatively young and healthy people with no signs of cardiovascular disease. Abnormalities in the BK channel may be one factor behind
the spasm, and he and his colleagues are now studying a “BK-channel agonist”
compound that may act to prevent this kind of spasm.
THE STATE OF THE HEART
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ADULT CONGENITAL HEART DISEASE PROGRAM
HEARTS IN THE RIGHT PLACE
In the 1950s, if a baby was born “blue”—with
a heart defect called transposition of the great
vessels, in which the aorta and the pulmonary
artery are connected to the wrong chambers—the parents were usually told that there
was no hope. Eight out of 10 of these infants
died within their first year of life. Virtually
none lived to their fifth birthday. But in 1963,
Dr. William Mustard performed a groundbreaking surgical procedure that would be
named after him, restoring the circulation
while reversing the blood flow in the heart—
and radically reversing the survival rate for
these children. It would soon be followed by
many other surgical innovations designed to
correct other defects.
Twenty years later, as a fellow at
Massachusetts General Hospital in the mid1980s, Marlon Rosenbaum, M.D., found
himself treating some of these “Mustard graduates”—the first generation of children with
complex heart defects to survive into their 20s
and 30s. He realized that he was present at the
creation of a new subspecialty: adult congenital cardiology.
About half a million adults in the United
States are living with complex congenital
heart conditions. And just as pediatric heart
patients aren’t “small adults,” adults who have
had congenital heart disease since childhood
aren’t merely “big children.” They have
outgrown the expertise of their pediatric cardiologist, but the average adult cardiologist is
often baffled by the unique anatomy and
complex medical issues that these patients face.
“They often have residual abnormalities,
such as leaky valves, and they can frequently
develop complex arrhythmias,” says Dr.
Rosenbaum, the founder and Director of the
Joan and Michael Schneeweiss Center for
Adult Congenital Heart Disease at Columbia,
one of only a handful of such programs in the
country and one of the few to offer three
full-time surgeons with expertise in adult congenital heart disease. “They really need to be
treated at a center that specializes in their
needs.” But there are only 22 physicians in the
entire country specializing in adult congenital
heart disease full-time.
As surgical approaches to congenital heart
defects have evolved, each new generation of
patients present with different repairs, different heart structure—and different ongoing
needs. “Someone born in the 1970s with a
transposition of the great arteries would have
had the Mustard procedure, for example,
which creates its own problems,” says Dr.
Rosenbaum. “On the other hand, someone
with the same anatomy born in 1990 would
have undergone an arterial switch, which
returns the two arteries to the appropriate
chambers—and which creates an entirely different set of issues. Every patient who comes
to see us is different.”
“And thus the heart will break, yet brokenly live on.”
Lord Byron
THE STATE OF THE HEART
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Just as the surgeries that correct congenital
heart defects are changing, so too is the specialty of adult congenital heart disease. “It’s a
continually evolving field. What I recommend
today in terms of replacing a pulmonary
valve, for example, I didn’t do even two years
ago,” says Dr. Rosenbaum.
YOUNG AT HEART
When Betsy Carlough was born in 1955, doctors knew there was something
wrong with her heart within two days. X-rays showed that she had Ebstein’s
anomaly, a malformation of the heart’s tricuspid valve. One or two of the three
leaflets of the valve were stuck to the wall of the heart, which meant they
couldn’t move normally.
But back then, there was nothing they could do except hope that the defect’s
Many adult congenital heart patients have
arrhythmias—heartbeats that are too slow,
too fast, or irregular. In the normal heart, the
source of an arrhythmia can usually be determined with little trouble. But in congenital
patients, localizing an arrhythmia can be a
detective story worthy of Sherlock Holmes.
“Probably 20% of our patients have arrhythmias, and finding them and treating them
isn’t easy,” says Dr. Rosenbaum. “Areas of
abnormal conduction can be difficult to reach
because of scarring, pathways may have been
changed, and multiple circuits can be involved
rather than just one.”
effects on her heart function would be mild. The infant Betsy went home with
her parents and spent the next 50 years seeing cardiologists regularly. She
knew that it was possible that the malformed valve was leaking and blood from
the right ventricle was flowing backward through the valve with each heartbeat, but as she grew up, she didn’t feel like a heart patient.
“I started running at the age of 20, and I would run about 10 miles a day with
no problem,” says Betsy, an office administrator for a general surgeon. “But in
my 40s, I began to notice that I couldn’t run as far, and I’d have to stop and
rest more often. At first I put it down to just getting older.” In early 2001,
Betsy’s cardiologist told her that it was time for her to see a specialist. “He
couldn’t take me further, so he sent me to Dr. Rosenbaum.”
Tests at Columbia revealed that although Betsy may have felt fine, her heart
was in terrible shape. “My echocardiogram looked horrendous,” she recalls. It
revealed that she had advanced heart disease and severe arrhythmias. “Dr.
Rosenbaum came back and told me that I needed surgery and that I probably
should have had it 10 years ago. I hadn’t even known there was a surgery for
me 10 years ago!”
Columbia’s surgical team repaired the tricuspid valve defect. At the same time,
they performed a MAZE surgical procedure, curing Betsy’s atrial fibrillation by
making incisions in both atria, interrupting the circular electrical patterns that
cause arrhythmias and channeling the normal electrical impulses in the proper
direction.
“I walked out of the hospital feeling 20 years younger!” she declares. “I was
kicking myself, wondering why I hadn’t done this before. I can’t believe how
good I feel.”
That’s why the adult congenital program has
its own state-of-the-art echocardiography lab,
along with a close collaborative relationship
with other cardiac specialists, such as electrophysiologist Hasan Garan, M.D. “We have a
depth of local expertise that makes our program different from all the others,” says Dr.
Rosenbaum.
That expertise—and Columbia’s renowned
maternal-fetal medicine program—plays an
important role for the increasing number of
young women with congenital heart defects
who hope to have children of their own. Until
very recently, women who had undergone surgeries for severe congenital defects as children
and now wanted to become pregnant were
given very simple advice: don’t. Pregnancy was
thought to place too much of a strain on an
already overtaxed heart.
DOES THE HEART RULE THE HEAD?
There’s a one-in-five chance that you could have a heart defect without even
realizing it. The defect is called a patent foramen ovale (say it “oh-VAL-ay”), and
it’s simply an opening in the septum, or wall, between the two upper chambers
of the heart (the right and left atrium). About 20% of the population has an
opening like this, and for most of these people, it never causes any problems.
But in some cases, when a person with a patent foramen ovale coughs,
sneezes, or otherwise creates pressure inside the chest, unfiltered blood with
debris—like small blood clots—can pass through the hole between the two
atria and lodge in the brain, heart, eyes, or kidneys. Blood traveling between
the atrial chambers of the heart may cause fatigue, shortness of breath, atrial
fibrillation, or other arrhythmias. Scientists are now studying whether or not
these defects may also be associated with an elevated risk of stroke in some
cases. “Why do some people with PFOs have problems, while most others
never even know they have them? It’s unclear,” says Robert Sommer, M.D.,
Director of the Adult Invasive Congenital Heart Services at the Center for
Interventional Vascular Therapy, who has performed more than 1,000 closure
procedures for PFOs and other atrial septal defects.
As more surgical breakthroughs happened
and more adult congenital heart patients felt
healthy and strong, some of these women
took a leap of faith—and so far, it appears
that many are doing well. “Anecdotally, we’ve
learned that if a woman with congenital heart
disease is asymptomatic before getting pregnant, she probably can successfully get
through the pregnancy—although regular and
careful cardiac evaluation is important,” says
adult congenital heart disease expert Deborah
Gersony, M.D.
But that’s not the end of the story. “What kind
of toll does it take on their body in the long
term?” she asks. Could pregnancy ultimately
damage a woman’s right ventricular function,
leading to increased levels of valvular disease
and potential complications down the road?
Those questions need to be answered, says Dr.
Gersony, so that women can make the most
informed decisions possible about pregnancy.
To help find answers, she is now leading a
prospective, multicenter study evaluating the
changes in ventricular function that occur
during pregnancy among women with three of
the more complex congenital heart conditions.
“This is an exciting field to be in,” she says.
“It’s very young, and it’s very positive. There’s
so much promise.”
When surgeons like Dr. Sommer began operating to close PFOs, they made a
serendipitous discovery. Some of these patients, who had suffered from severe,
classic migraines complete with “auras” for much of their lives, suddenly found
that their migraines were gone.
Scientists aren’t sure precisely how PFOs might contribute to migraines, but
there appears to be an association. Some 12% of all people have classic
migraines, and of that group, about 70% to 75% have PFOs—far more than in
the general population. Two smaller studies published in early 2005 found a
dramatic reduction in migraines among patients who’d had PFO closure surgeries.
Now Dr. Sommer and his team are among the investigators launching two
large, randomized clinical trials designed to assess whether closing PFOs helps
to prevent migraines—one using radiofrequency energy to seal the wall, and
the other using a device that closes the hole.
“Migraines are extremely debilitating, and if closing the PFO can alleviate
migraines, it would make an enormous difference for so many people,” says
Dr. Sommer.
THE STATE OF THE HEART
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25
PREVENTION AND WOMEN’S HEALTH
HOME IS WHERE THE HEART IS
because of inherited factors or because of
their lifestyle habits, you may be at risk too.”
“When the body is sad, the heart languishes.”
Albert Camus
You have your mother’s eyes and your grandfather’s nose. You trade clothes with your
sister, and never miss spending the holidays
with your cousins. But you have a lot more in
common with your family than just resemblances and memories. With our families, we
share both our genetic heritage and our daily
lives: two things that can put us all at higher
risk for heart disease.
Heart health is a family affair, says Lori
Mosca, M.D., Ph.D. The founder of Columbia
University Medical Center’s groundbreaking
Preventive Cardiology Program, Dr. Mosca is
on a mission to reach out to at-risk families
and educate them on how to live heart
healthy. It’s a very personal lesson: her father
suffered a heart attack during her second year
in medical school. Fortunately, he survived,
but the ordeal her family went through
inspired in Dr. Mosca a passion for prevention: intervening to stop cardiovascular
disease before it causes damage.
“We don’t live in isolation,” she says. “With
our families, we share our lifestyles as much as
we share our genes, so if someone in your
family is at an elevated risk of heart disease
With that in mind, Dr. Mosca and her team
created the “Passport to Heart Health” program, a unique screening project aimed at the
families of patients who have been admitted
to Columbia University Medical Center in a
cardiac crisis. “This is a motivational moment
at which we can help families assess their own
risk,” she says. “If we can identify people at
elevated risk and direct them to early intervention, we can reduce the burden of
cardiovascular disease.”
Cardiac prevention counselors screen family
members of heart patients not only for traditional risk factors such as blood pressure,
cholesterol, and glucose but also for newer
risk factors such as C-reactive protein, an
indication of inflammation. Then they talk
with the families about heart-healthy lifestyles.
After its first four years, the program has
found a previously unrecognized and undermanaged level of heart disease risk among
screened family members. What’s more, says
Dr. Mosca, early research suggests that those
risk factors improve after education from
Passport program counselors.
The first-of-its-kind program has proven so
successful that it’s being exported to other
hospitals that serve a variety of socioeconomic
groups, both elsewhere in New York and as
far away as Canada. Recently, the National
Institutes of Health awarded Passport to Heart
Health a $2 million grant to study the effectiveness of its interventions.
All too often, prevention messages about heart
disease miss an enormously important target:
women. Heart disease is the No. 1 killer of
women—but although it kills 10 times more
women every year than breast cancer, many
surveys show that women worry far more
about breast cancer.
Women—and all too often, their doctors—are
likely to miss the signs of heart trouble, says
THE STATE OF THE HEART
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THE ANGRY HEART
Remember “type A” personalities? A buzz term of the 1980s, “type A”
referred to people in a constant, impatient hurry: the ones who can’t stand to
wait in line at the bank or the grocery store and make work-related cell phone
calls while at the miniature golf course with their kids. They’re hyper-competitive, easily irritated, and always on the move.
It was once thought that “type A” people were at higher risk of heart attacks,
but research revealed that wasn’t the case. Type As overall don’t have more
heart attacks or sustain more heart damage than people who poke along in
life’s slow lane. But doctors are beginning to understand that there is a certain
subset of type A people who may indeed face greater heart risks: the angry ones.
Anger, it turns out, might be just as bad for your heart as sitting on the couch
all day with a bag of greasy potato chips in one hand and a cigarette in the
other. “Current known risk factors only explain about half of all heart attacks,”
says Daichi Shimbo, M.D. He is researching behavioral cardiovascular health—
how our lifestyles affect our hearts. “Most of the rest of heart attacks appear to
be caused by psychosocial factors. In fact, studies have found that chronic
stress, anger and depression are almost as bad for your heart as diabetes is.”
Dr. Shimbo has been studying the effects of anger on endothelial function—
that is, how blood vessels behave—by conducting a series of interviews with
groups of volunteers. Some interviews are “neutral,” with no provocative questions asked; in others, the interviewer asks condescending and patronizing
questions designed to provoke anger. The results, he says, have been dramatic.
“Beginning about 30 minutes after the ‘angry’ interviews, the arteries’ ability to
dilate just plummets. They become almost as constricted as they would be if
the person had been smoking for 20 years.”
Next, Dr. Shimbo plans to study how long it takes the endothelium to recover
from the “shock” of anger, and also to explore what can be done to prevent
long-term damage for people who are chronically angry.
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THE STATE OF THE HEART
Elsa-Grace Giardina, M.D., founder and
Director of Columbia’s Center for Women’s
Health. “Women with a heart attack may present with very different complaints than do
men,” Dr. Giardina says. “They often experience vague and nonspecific symptoms like
shortness of breath, nausea, fatigue, or left
arm pain.”
And after heart attacks, women fare less well
than men. Women under 50 are about twice
as likely as men to die following a heart
attack. And women are almost two times as
likely as men to die after bypass surgery.
Meanwhile, they’re less likely to receive certain
vital therapeutic interventions, like angioplasty, aspirin therapy, and cardiac stents.
To help understand which women are at
particularly high risk for heart disease, Dr.
Giardina is studying novel markers for cardiovascular risk. “We all know about cholesterol
and high blood pressure,” she says. “I’m interested in a class of markers that help us predict
which women have an elevated risk of heart
disease without any of the traditional signs.”
These markers, called hemostatic and fibrinolytic
factors, fluctuate over the course of a woman’s
menstrual cycle. “We’ve just begun to define
their role, but they may be useful to help us
understand what role estrogen plays in heart
disease and stratify risk so that we can intervene early for high-risk patients.”
Dr. Mosca and Dr. Giardina are also working
with the Sister to Sister/Everyone Has a Heart
program, to get the word out about women
and heart disease. In 2005 alone, Columbia
physicians provided free heart disease screenings for more than 10,000 women as part of
the Sister to Sister program. “It’s imperative
that we keep women healthy, or we’ll be a
nation that takes care of a huge population of
debilitated, elderly women,” says Dr. Giardina.
“The question isn’t just whether you’re going to
live or die—it’s how well are you going to live?”
FELLOWSHIP
HEARTS AND MINDS
Today’s fledgling cardiologist must master
tools and technologies that were virtually
unknown to their predecessors entering the
field just 10 years ago—from drug-eluting
stents to using magnetic resonance imaging to
study the heart. Cardiovascular medicine is
evolving so rapidly that Columbia’s cardiovascular fellowship program, a leader in training
the heart specialists of tomorrow for more
than 20 years, has reshaped its curriculum
extensively to meet the evolving needs of its
fellows.
“In the past few years, there’s just been an
explosion in technical knowledge, therapeutic
modalities, and evidence-based medicine documenting what cardiology should be,” says
James Coromilas, M.D., Director of the
Cardiology Fellowship Program. “Areas that
were nonexistent 15 years ago, like cardiac
MRI and fast CT, device therapies, and electrophysiology with ablation, are now a part of
everyday practice.”
The highly competitive program attracts
more than 500 applicants for six slots annually.
Fellows can choose either a three-year or
four-year program: a three-year clinical
track that includes a standard two-year core
curriculum and a third year divided between
clinical rotations and subspecialty research,
or a four-year research track that adds two
years of intensive research training to the
initial two-year curriculum.
To its standard rotations in cardiac catheterization, echocardiography, nuclear cardiology,
adult congenital heart disease, and the coronary care unit, Columbia’s fellowship program
has added new rotations in peripheral vascular disease, rehabilitation medicine, preventive
cardiology, and noninvasive imaging. “That’s
in addition to our heart failure and transplant
rotations, which are among the most extensive
in the country,” says Dr. Coromilas. Columbia
is one of only a handful of cardiovascular fellowships in the nation offering rotations in
transplant and in adult congenital heart disease.
As the depth, breadth, and complexity of the
fellowship program has increased over the
years, so has the caliber of its fellows. “We’ve
always had outstanding candidates for our fellowship program, and their qualifications just
continue to improve,” says Dr. Coromilas.
“The skills, knowledge base, and prior
research experience of each incoming group is
much more extensive than in past years.” In
recognition of the excellence of our faculty
and our commitment to training leaders in
academic cardiology, the program is partially
supported by a competitively awarded NIH
training grant.
These Columbia-trained thought leaders in
cardiology will play an essential role in bringing new ideas, energy, and perspective to a
specialty whose importance will only increase
as the population ages. “With the aging of the
Baby Boom generation, the volume of cardiovascular disease is already increasing greatly,
and we can expect that to continue,” says Dr.
Coromilas. “Meanwhile, there’s a growing
shortage of cardiovascular specialists in the
country.”
In the midst of an expanding knowledge base,
ever-evolving technologies, and increasing
pressures on young physicians, Dr. Coromilas
maintains a clear focus for the fellowship program: creating the next generation of leaders
in cardiovascular disease. “As cardiology
becomes more and more specialized, it’s more
important than ever that cardiologists have a
strong grounding in the fundamental principles of cardiovascular medicine,” he says.
“Where my heart lies let my brain lie also.”
Robert Browning
THE STATE OF THE HEART
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31
The Vivian and Seymour Milstein Family Heart Center
But the Heart Center is only one piece of
the puzzle. If we are to bring tomorrow’s
discoveries to our patients—if we are to take
advantage of the revolution in molecular
biology, genomics, and proteomics—we must
have the kind of 21st-century laboratories and
facilities that will attract and retain the finest
minds working in cardiology today.
32
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THE STATE OF THE HEART
Photography: Paul Schneck
To bring these experts together in a way that
best meets the needs of our patients, we are
creating an entirely new facility: The Vivian
and Seymour Milstein Family Heart Center,
uniting the world’s finest cardiovascular physicians and nurses, and the latest in diagnostic
and treatment tools and technologies, all
under one roof. In this remarkable five-story,
115,000-square-foot building adjacent to the
Milstein Hospital Building and Herbert Irving
Pavilion—a first-of-its-kind facility for New
York City—science will be brought to the bedside as clinical experts work closely with basic
science researchers, translating the latest scientific discoveries into new treatment options.
To achieve that goal, we will soon be launching
an ambitious campaign. Our plan is to ensure
that Columbia University Medical Center is
second to none in our programs for state-ofthe-art cardiovascular science, bringing
together researchers from physiology, pharmacology, surgery, and medicine to build a
bridge between the bench and the bedside.
As these plans proceed, our challenge will be
to provide the space and resources needed to
recruit and retain the best and the brightest
in fields such as cardiovascular genetics and
vascular biology, two of the most important
growth areas in cardiology today. As these
plans move forward, we hope to work with
all of you in making this dream a reality.
Copy: Gina Shaw
Just as the valves, vessels, chambers, and
membranes of the heart work as a seamless,
integrated whole to pump blood through the
body, so too do Columbia’s many expert physicians in many subspecialty areas of cardiology
work together to bring extraordinary care to
our patients. For example, interventional cardiologists and electrophysiologists consult with
clinical cardiologists to determine the optimum treatment for patients with coronary
disease. Cardiovascular ultrasound experts and
nuclear cardiologists collaborate with heart
failure specialists to determine the extent of
heart damage. And all of these leading cardiovascular physicians collaborate on the cuttingedge basic, translational, and clinical research
that will lead to the breakthrough therapies of
the future.
Design: h george design, inc., NYC
THE FUTURE OF CARDIOLOGY AT COLUMBIA
With a strong cadre of nationally recognized
senior cardiovascular scientists, as well as a
growing number of aggressively recruited
young investigators who represent cardiology’s
future, Columbia’s cardiovascular research
program has already pushed the boundaries
of possibility. But with research taking place
in multiple different departments, geographically dispersed across campus without any
coordinating infrastructure, only so much can
be achieved. To integrate basic and applied
research and speed the progress of discovery
into clinical practice, we must bring these
researchers and their programs together.
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DIRECTORY